What are the treatment options for thoracic back pain with radiating numbness and tingling to the legs when getting up from a lying position?

Urgent Evaluation for Thoracic Myelopathy Required

Your patient's presentation of thoracic back pain with radiating numbness/tingling to the legs that occurs specifically when transitioning from lying to standing represents a red flag symptom requiring immediate MRI thoracic spine without contrast to rule out myelopathy or spinal cord compression. 1

Why This Is Urgent

The positional nature of your patient's symptoms—specifically the provocation when getting up from lying down—is listed as an alarm symptom for spinal instability and/or myelum compression in patients with thoracic pathology 1. This pattern, combined with bilateral lower extremity neurological symptoms, suggests potential:

• Thoracic myelopathy from cord compression (most common cause is spinal stenosis from disc herniation below T7, facet arthropathy, or ligamentum flavum ossification) 1
• Spinal instability that worsens with positional changes 1
• Epidural compression that becomes symptomatic with postural transitions 1

Immediate Diagnostic Algorithm

Step 1: Perform Focused Neurological Examination

Look specifically for:

• Motor weakness in legs (difficulty controlling legs, wobbly gait, legs giving way) 1
• Sensory level (numbness/tingling radiating from chest, stomach, groin, or legs in dermatomal pattern) 1
• Spasticity/hyperreflexia (present in 58% of symptomatic thoracic disc herniations) 1
• Positive Babinski sign (present in 55% of cases) 1
• Bladder dysfunction (difficulty initiating urination or retention—present in 24% of cases) 1

Step 2: Order MRI Thoracic Spine Without IV Contrast Immediately

MRI thoracic spine without contrast is the initial imaging modality of choice for thoracic back pain with myelopathy or radiculopathy. 1, 2 This should be performed:

• Within 12 hours if clinical suspicion of myelum or cauda compression exists 1
• Within 2 weeks if only local back pain without clear neurological deficits 1

Given your patient's bilateral leg symptoms with positional provocation, err toward the 12-hour timeframe 1.

Step 3: Screen for Additional Red Flags While Awaiting MRI

Malignancy risk factors: 2, 3

• Age >50 years
• History of cancer
• Unexplained weight loss
• Constant pain unrelieved by rest
• Pain worse at night when lying down

Infection risk factors: 2, 3

• Fever or recent infection
• Immunosuppression
• IV drug use
• Constant pain with systemic symptoms

Fracture risk factors: 2, 3, 4

• Age >65 years
• Chronic steroid use
• Known osteoporosis
• Midline tenderness on examination
• Significant trauma history

If any of these are present, upgrade to MRI with and without contrast to evaluate for metastatic disease, infection, or epidural abscess 2, 3.

Common Pitfalls to Avoid

1. Do not dismiss positional symptoms as benign musculoskeletal pain. Back pain that occurs specifically when lying down and improves with sitting up is an alarm symptom for spinal metastases or instability 1.

2. Do not order plain radiographs or CT first. These cannot exclude spinal cord compression or myelopathy 1. MRI is superior for demonstrating spinal metastases, epidural compression, and MESCC 1.

3. Do not wait for "complete" neurological deficits. Numbness and tingling radiating to the legs already constitutes a neurological deficit requiring urgent imaging 1.

4. Do not assume bilateral symptoms mean "non-organic" pathology. Thoracic myelopathy commonly presents with bilateral lower extremity symptoms due to central cord involvement 1.

Most Likely Diagnoses Based on Presentation

Primary Concern: Thoracic Disc Herniation with Cord Compression

• Occurs most commonly below T7 1, 2
• Presents with thoracic midback pain (76% of cases) and motor/sensory deficits (61% of cases) 1
• Often calcified (20-65% of cases) 1, 2
• One-third have trauma history 1, 2
• Surgical indication: severe intractable pain or progressive/severe myelopathy 1

Alternative Considerations:

• Spinal stenosis from facet arthropathy or ligamentum flavum ossification 1, 2
• Thoracic radiculopathy from mechanical nerve root compression 1
• Spinal metastases (if cancer history or other red flags present) 1, 2

Treatment Pathway After Imaging

If MRI confirms compressive myelopathy: 1

• Urgent neurosurgical or spine surgery consultation
• Surgery indicated for progressive neurological deficits or severe intractable pain
• Conservative management only appropriate for mild, stable symptoms without progression

If MRI shows radiculopathy without myelopathy: 5

• Conservative treatment with WHO pain ladder medications
• Physical therapy/manual therapy
• If conservative treatment fails after 4-6 weeks, consider pulsed radiofrequency treatment of the dorsal root ganglion (recommendation 2C+)

If MRI is negative but symptoms persist: 1

• Consider CT myelography as complementary study to assess spinal canal patency
• Evaluate for non-compressive causes (inflammatory, vascular, metabolic)

Special Population Considerations

If patient is elderly (>65 years): Lower threshold for imaging due to increased fracture and malignancy risk 2, 3.

If patient has prior spinal surgery: Requires early imaging regardless of symptom duration 2, 3.

If patient has known cancer: Full spinal column MRI (not just thoracic) to assess for multiple metastatic sites 1.